Totality Home Health Care Agency LLC

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on review of the clinical records, review of agency policies, surveyor observation and interview with agency personnel, for five of eight patients (Patients #2, 3, 4, 5 and 8) in the survey sample, the agency nurses failed to follow the agency policies and procedures regarding wound measurements, timely documentation, medication reconciliation, pre-pour documentation and/or direct supervision of the Licensed Practical Nurse/LPN. The findings include: Patient #3 had a start of care date of 7/14/19 and diagnoses that included type II diabetes mellitus, asthma and illiteracy. Physician’s orders for the certification period of 4/18/24 to 6/16/24 included nursing services seven times a week for insulin administration. Interview and review of the May 2024 nursing visit schedule with the Administrator on 5/07/24 at 1:05 PM identified nursing visits daily by LPN #1 from 5/02/24 through 5/07/24 but failed to identify that the notes were synchronized in the electronic record within twenty-four hours according to agency policy. Review of agency policy for Protection of Medical Records directed that documentation must be returned to the agency within twenty-four hours of the most recent home care visit pertinent to that discipline and filed in the clinical record within seven days. Patient #4 had a start of care date of 7/15/19 and diagnoses that included type II diabetes mellitus, hypertension and glaucoma. The physician’s orders for the certification periods of 2/04/24 to 6/02/24 included nursing services one to two times a week for medication pre-pouring and assessments and home health aide services three to five times a week for assistance with personal care. During a joint home visit on 5/07/24 at 10 AM, the surveyor observed LPN #1 begin pre-pouring the patient’s medications without the benefit of a medication profile. Subsequent to surveyor inquiry, LPN #1 removed the paper medication profile from the storage container but failed to follow/ensure all the medications on the profile were pre-poured. Physician’s orders on the medication profile included Cyclobenzaprine Hydrochloride 10 milligrams/mg twice daily, Simvastatin 10 mg every night, Vitamin D 5000 units weekly on Monday, Phentermine 37.5 mg daily, Linzess 72 micrograms/mcg daily and Metformin Hydrochloride 1000 mg twice daily but were not pre-poured. Subsequent interview with LPN #1 and Patient #4 identified that the above medications were discontinued. Interview and review of the surveyor’s observations and the medication profile with the Administrator on 5/07/24 at 1:10 PM failed to ensure an accurate medication profile and failed to ensure agency nurses updated the medication profile with medication changes. Subsequent to surveyor inquiry, LPN #1 notified the physician and clarified the above medications were discontinued and updated the medication profile. Review of the agency policy for Medication Reconciliation directed the medication profile will be updated when orders change, or client adds/discontinues other over the counter medications. An updated medication profile will be present in the client’s home or electronic medical record for all staff involved in the care. Patient #5 had a start of care date of 2/27/24 and diagnoses that included acute systolic heart failure, hypertension and encephalopathy. Physician’s orders for the certification period of 3/04/24 to 5/02/24 included nursing services once weekly for weight monitoring and assessments. Interview and review of the nursing notes from 3/04/24 through 4/29/24 (eight weeks) with the agency Administrator on 5/07/24 at 1 PM identified that the LPN completed the weekly nursing visits and failed to identify an RN supervisory visit was completed directly while the LPN was providing care to the patient once every thirty days, according to agency policy. Review of agency policy for supervision of LPN’s directed in part that all LPN’s will be supervised directly while providing care once every thirty days. Patient #8 had a start of care date of 2/27/24 and diagnoses that included stage II pressure ulcer of the left heel, type II diabetes mellitus and acute kidney failure. The physician’s orders for the certification periods of 2/27/24 through 6/25/24 included nursing services two to three times a week for assessments and wound care to the left heel. Interview and review of the clinical record with the Administrator on 5/06/24 at 3:10 PM identified twice weekly LPN nursing visits but failed to identify documentation of wound measurements by LPN #1 for the weeks of 3/04/24 through 4/03/24 (four weeks) and the three time a week nursing visits from 4/16/24 to 4/20/24 and 4/29/24 to 5/04/24 and failed to follow agency policies for weekly wound measurements. Patient #2 had a start of care date of 01/10/2022 with diagnoses of multiple sclerosis, muscle contractures, stage three pressure ulcers (full thickness tissue loss) to the right and left buttocks and a gastronomy tube (a tube inserted through the abdominal wall into the stomach to provide nutrition). The physician orders for the certification period of 03/04/2024 through 05/02/2024 included nursing services once per week for nine weeks for nursing assessments, wound care, feeding tube assessments and weekly medication pre-pours. i. Interview and review of Patient #2’s clinical record with the Administrator on 05/07/2024 at 11:45 AM, failed to identify the Patient’s stage three pressure ulcers to the right and left buttocks were measured on 03/13/2024, 03/20/2024, 03/27/2024, 04/03/2024, 04/10/2024, 04/16/2024 and 04/22/2024 in accordance with the agency’s Wound Care policy. Additionally, the Administrator failed to identify the Patient’s weekly medication pre-pours were documented on 03/13/2024, 03/20/2024, and 03/27/2024 in accordance with the agency’s Medication Administration policy. Review of the agency’s Wound Care policy identified the initial and ongoing assessments of skin integrity and identified wounds would be conducted as part of the routine nursing assessments. Full reassessment with complete measurements and documentation would be done at minimum weekly and with any significant change. Wound assessment would include but not limited to length, width, depth, exudate, drainage, tissue description, margins, etc. Review of the agency’s Medication Administration policy identified medication pre-pours for patient/caregiver administration would be documented as “Medications pre-poured for the number of days and for the period of, as per the medication profile date.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record review, review of agency policies and interviews with agency personnel for two of eight patients (Patient’s #1 and #8) in the survey sample, the agency failed to ensure an accurate and authentic record. The findings include: Patient #1 had a start of care date of 9/09/22 and diagnoses that included type II diabetes mellitus, dysthymic disorder and chronic pain. Physician’s orders for the certification period of 3/02/24 to 4/30/24 included nursing services three to five times a week for insulin administration and home health aide services three to five times a week for assistance with personal care. Physician’s order included Trulicity (an insulin for blood sugar control) 0.75 milligrams/0.5 milliliters subcutaneously weekly. i.Interview and review of the March 2024 and April 2024 Medication Administration Records/MAR with the Administrator on 5/07/24 at 12:55 PM failed to identify the initialing of the administration of the weekly Trulicity injections on 3/12/24, 4/05/24, 4/12/24, 4/19/24 and 4/26/24 by RN #1, although, subsequent to surveyor inquiry, RN #1 indicated that the Trulicity injection was administered weekly as ordered. Patient #8 had a start of care date of 2/27/24 and diagnoses that included stage II pressure ulcer of the left heel, type II diabetes mellitus and acute kidney failure. The physician’s orders for the certification periods of 2/27/24 through 6/25/24 included nursing services two to three times a week for assessments and wound care to the left heel. i.Interview and review of the clinical record with the agency Administrator on 5/06/24 at 3:10 PM identified that nursing visit documentation by LPN #1 was not incorporated in the clinical record for visits that occurred on 4/16/24, 4/20/24, 4/21/24, 4/26/24, 4/29/24, 5/02/24 and 5/04/24 until the surveyor identified the deficient practice, and failed to identify conformance with the agency policies and procedures which directed the documentation of clinical notes in the patient’s records within seven days of the delivery of service. Review of agency policy for Protection of Medical Records directed that documentation must be returned to the agency within twenty-four hours of the most recent home care visit pertinent to that discipline and filed in the clinical record within seven days.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record review, review of agency policies and interview with agency personnel, for two of five patients (Patient’s #1 and #3) with a diagnosis of type II diabetes mellitus, requiring blood glucose monitoring and daily insulin administration, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs and the agency nurses failed to clarify insulin administration times with the physician. The findings include: Patient #1 had a start of care date of 9/09/22 and diagnoses that included type II diabetes mellitus, dysthymic disorder and chronic pain. Physician’s orders for the certification period of 3/02/24 to 4/30/24 included nursing services three to five times a week for insulin administration and home health aide services three to five times a week for assistance with personal care. i.Interview and review of the physician’s certified plan of care dated 3/02/24 with the Administrator on 5/07/24 at 12:55 PM failed to identify communication with the physician for the frequency of blood glucose monitoring and parameters for reporting abnormal findings to the physician. Physician’s order included Basaglar KwikPen (a long-acting insulin) 100 units/milliliter, administer 48 units subcutaneously daily and Trulicity (an insulin for blood sugar control) 0.75 milligrams/0.5 milliliters subcutaneously weekly. ii.Interview and review of the physician’s certified plan of care dated 3/02/24 and the nursing notes dated 3/04/24 to 4/30/24 with the Administrator on 5/07/24 at 12:55 PM, identified nursing visits Monday through Friday from 9:32 AM to 11:15 AM for insulin administration, but failed to clarify with the physician, specific times to administer the Basaglar and Trulicity insulin, the specific day to administer the Trulicity insulin, and failed to identify documentation of the caregiver administering the insulin on the weekends, and failed to ensure the care plan addressed the patient’s needs. Patient #3 had a start of care date of 7/14/19 and diagnoses that included type II diabetes mellitus, asthma and illiteracy. Physician’s orders for the certification period of 4/18/24 to 6/16/24 included nursing services seven times a week for insulin administration. Physician’s orders included Lantus insulin (a long-acting insulin) 100 units/milliliter, administer 14 units subcutaneously daily and Trulicity 1.5 milligrams/0.5 milliliters, inject 1.5 milliliters subcutaneously weekly. Interview and review of the physician’s certified plan of care dated 4/18/24 and the nursing notes from 4/18/24 to 4/30/24 with the Administrator on 5/07/24 at 1:05 PM, identified nursing visits daily between 10:40 AM and 11:20 AM for insulin administration, but failed to clarify with the physician, specific times to administer the Lantus and Trulicity insulin, the specific day to administer the Trulicity insulin, and failed to ensure the care plan addressed the patient’s needs. Review of agency policies for Comprehensive assessment directed a review of all medications the patient is using, general health status and system assessment.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on review of the clinical record, surveyor observation and interview with agency personnel, for one of three patients (Patient #3) requiring medication management, the agency nurses failed to clarify which medications would be administered by the agency. The findings include: Patient #3 had a start of care date of 7/14/19 and diagnoses that included type II diabetes mellitus, asthma and illiteracy. Physician’s orders for the certification period of 4/18/24 to 6/16/24 included nursing services seven times a week for insulin administration. Physician’s orders directed the administration of Dorzolomide Hydrochloride-Timolol Maleate 2-05%, one drop in both eyes daily. During a joint home visit on 5/07/24 at 9:40 AM with LPN #1, the surveyor observed the administration of daily medications as ordered, and the pre-pouring of evening medications as ordered, but failed to include the administration of the eye drops as ordered. Interview and review of the plan of care and medication profile with the Agency Administrator on 5/07/24 at 1 PM, failed to clarify which medications the family manages and which medications the agency manages, but identified that the family administers the daily eye drops.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, for one of eight patients (Patient #4) in the survey sample, the agency nurses failed to communicate with the physician involved in the plan of care. The findings include: Patient #4 had a start of care date of 7/15/19 and diagnoses that included type II diabetes mellitus, hypertension and glaucoma. The physician’s orders for the certification periods of 2/04/24 to 6/02/24 included nursing services one to two times a week for medication pre-pouring and assessments and home health aide services three to five times a week for assistance with personal care. During a joint home visit on 5/07/24 at 10 AM, the surveyor observed LPN #1 begin pre-pouring the patient’s medications without the benefit of a medication profile. Subsequent to surveyor inquiry, LPN #1 removed the paper medication profile from the storage container, but failed to follow/ensure all the medications on the profile were pre-poured. Physician’s orders on the medication profile included Cyclobenzaprine Hydrochloride 10 milligrams/mg twice daily, Simvastatin 10 mg every night, Vitamin D 5000 units weekly on Monday, Phentermine 37.5 mg daily, Linzess 72 micrograms/mcg daily and Metformin Hydrochloride 1000 mg twice daily but were not pre-poured. Subsequent interview with LPN #1 and Patient #4 identified that the above medications were discontinued. Interview and review of the surveyor’s observations and the medication profile with the Administrator on 5/07/24 at 1:10 PM failed to ensure an accurate medication profile and failed to ensure agency nurses communicated with the physician with the medication changes. Subsequent to surveyor inquiry, LPN #1 notified the physician and clarified the above medications were discontinued and updated the medication profile.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of the clinical record review of agency policies and interview with agency personnel, for two of two patients (Patient’s #1 and #4) who received skilled nursing services along with home health aide services, the agency Registered Nurse/RN failed to provide onsite supervisory visits no less frequently than every 14 days. The findings include: Patient #1 had a start of care date of 9/09/22 and diagnoses that included type II diabetes mellitus, dysthymic disorder and chronic pain. Physician’s orders for the certification period of 3/02/24 to 4/30/24 included nursing services three to five times a week for insulin administration and home health aide services three to five times a week for assistance with personal care. Interview and review of the nursing notes from 4/05/24 to 4/30/24 with the Administrator on 5/07/24 at 12:40 PM identified that the RN conducted a home health aide supervision on 4/05/24, but failed to identify an onsite supervisory visit to Patient #1 by a Registered Nurse until 4/30/24 (a period of twenty-five days). Patient #4 had a start of care date of 7/15/19 and diagnoses that included type II diabetes mellitus, hypertension and glaucoma. The physician’s orders for the certification periods of 2/04/24 to 6/02/24 included nursing services one to two times a week for medication pre-pouring and assessments and home health aide services three to five times a week for assistance with personal care. Interview and review of the clinical record with the Administrator on 5/07/24 at 12:45 PM identified that the RN conducted onsite home health aide supervisions along with the recertification visits on 1/30/24 and 4/03/24, the Licensed Practical Nurses/LPN conducted the bi-weekly nursing visits in the subsequent weeks and failed to identify onsite supervisory visits to Patient #4 by a Registered Nurse from 2/13/24 to 4/03/24 (a period of forty-nine days). Review of the agency policy on Home Health Aide Supervision directed when skilled services are being provided, the RN/Therapist must make a supervisory visit to the patient’s residence at least every two weeks.”